Tuesday, April 17, 2012

Bed Wetting

Bed Wetting

Nocturnal enuresis, more commonly known as bed wetting, is often a source of significant frustration for parents and has the potential to be a source of poor-self esteem for children. 

Bed wetting is a very common condition for young children, especially those who are in the process of being toilet trained or those who have been recently trained to use the bathroom.  It is estimated that up to 7 million children are affected by nocturnal enuresis.  Data from Pediatrics in Review states that the prevalence of frequent bed wetting is 25% in children who are 4 years old.  This decreases to 15% by age 5 years and 10% at 6 years old.  After age 10, less than 5% of children will still have trouble with bed wetting. 

A diagnosis of enuresis (wetting) is usually not given until a child continues to have periods of inappropriate daytime or nighttime urination beyond an age where dry nights are expected, usually by age 5.  Having some nights where a child will wet themselves after completing toilet training is common and does not require intervention, so long as the frequency per week is decreasing over a period of a few months. 
·         A Pediatrics in Review article by Lawless and McElderry, states that having one or both parents who also had difficulties with bed wetting as a child increases the probability of their child also having nocturnal enuresis to 77%.
The vast majority of cases are not related to an organic medical condition, but rather caused by many contributing processes which as the percentage of children affected (above) shows, usually resolves on its own.
·         NEVER punish a child for wetting themselves or the bed.

Along with your pediatrician asking questions about your child’s daytime and nighttime bathroom habits and performing a physical exam to assess for causes of inappropriate wetting, there are several tips that parents can employ to limit the number of wet nights.
·         Limit the amount of liquid your child drinks 2 to 3 hours before bedtime.
o   One of the common causes of nighttime bed wetting is drinking too much prior to bedtime.
o   No caffeinated beverages during dinner or afterwards.  Also limit dairy products, juices, and chocolate 2 hours prior to bedtime.  Provide water if your child needs a drink.
·         Encourage your child to use the toilet before bed.  Have them sit for at least 2 minutes to allow them to feel the sensation/urge to urinate.  Try turning on the sink while they are sitting.
·         Have a nightly routine including regular bedtime.
·         Constipation is a common cause for new episodes of nighttime urination. 
o   Discuss with your pediatrician the need for a change in diet or medications to help relieve constipation which will often also relieve bed wetting.

A child who is having difficulty staying dry during the day or night following toilet training should be seen by their pediatrician and will likely have their urine analyzed for signs of infection or diabetes.  Often a simple urine test is the only laboratory exam that is needed.  In some cases, other exams, such as an ultrasound of the bladder and kidneys may need to be performed with referral to a pediatric urologist as needed.

A child must first be willing to be fully toilet trained and must have the full support of their parents during this time.  Both the child and parents should be aware that accidents will likely happen during the toilet training process.
·         Motivational therapy: supporting a child with positive reinforcement and a reward system (a small reward given for each night that they remain dry).  This is the first therapy that should be attempted.  Often requiring a 3-6 month commitment prior to adding another treatment method.
·         Behavioral therapy:  many different types of alarm systems (vibratory or acoustic) are available which alert a child, parent, or both when the first sign of wetness is detected on a child’s clothing.  These help to greatly reduce the number of nighttime bed wetting episodes when also combined with motivational therapy. 
o   Up to 70% of children are cured after utilized this therapy.  It is advised to continue using the device until the child has had three consecutive weeks of dry nights.
o   Another method known as dry-bed training involves waking the child on a schedule at decreasing intervals over several nights and having them walk to the toilet if they need to use the bathroom. 
§  This technique is fairly time and labor intensive and difficult for families to complete.
·         Medications:  there are a few medications which can be used to help limit the number of wetting episodes.  Medications are also useful for children who occasionally have nighttime wetting, but fearful that they may have an accident when they are not sleeping at home, such as a sleepover at a friend’s house.

Prior to starting any treatment for your child or for more information on bed wetting or treatment strategies, please talk with your pediatrician.

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1 comment:

  1. An excellent synthesis of the diagnosis and treatment of bedwetting! I found your website through your recent Twitter post about breastfeeding & obesity, Dr. Rudnick, and I look forward to more installments. Count me in as an eager follower! Thanks.